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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD60623 Project Vida Inc.
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Covered Entity Details
Entity Name
Project Vida Inc.
Subdivision Name
Project Vida Inc.
Type
Sexually Transmitted Diseases
340B ID
STD60623
Entity Address
2659 South Kedvale Ave
Chicago, IL 60623
Grant Number
NU62PS924560
Participating Start Date
7/1/2020
Last Recertification Date
5/16/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
6/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jerome Montgomery, Executive Director
(773) 426-5997
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
4/13/2020
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